Ultrasound imaging and central venous pressure in spontaneously breathing patients: a comparison of ultrasound-based measures of internal jugular vein and inferior vena cava.

BACKGROUND: Ultrasound evaluation of inferior vena cava and internal jugular vein dia-meters predicts the intravascular volume status in critical patients. The aim of the present study was to determine which ultrasound-derived index is most strongly associated with central venous pressure (CVP). Furthermore, we determined the utility of selected variables in predicting low volume status (CVP < 8 mmHg). METHODS: All patients underwent a transthoracic echocardiogram, vascular ultrasound examination, invasive central venous pressure, and intra-abdominal pressure determination. The following indexes were calculated: inferior vena cava diameter, internal jugular vein maximum diameter, collapsibility index, and internal jugular vein ratio. RESULTS: 41 spontaneously breathing patients were recruited. Central venous pressure significantly correlated with inferior vena cava diameter ( r = 0.35, P = 0.02), internal jugular vein ratio ( r = 0.35, P = 0.03), and internal jugular vein maximum diameter ( r = 0.58, P < 0.001). The inferior vena cava collapsibility index did not show any association. The areas under the receiver operating characteristic curves to discriminate a low central venous pressure (< 8 mmHg) were the following: internal jugular vein diameter 0.80 (95% CI: 0.63-0.90); inferior vena cava diameter 0.66 (95% CI: 0.49-0.80); and internal jugular vein ratio 0.68 (95% CI: 0.51-0.82). CONCLUSIONS: The internal jugular vein diameter, the internal jugular vein ratio, and the inferior vena cava diameter showed a significant correlation with central venous pressure. In particular, the internal jugular vein diameter showed good accuracy in predicting a low central venous pressure.

Multicenter observational study on the reliability of the HEART score.

OBJECTIVE: To rapidly and safely identify the risk of developing acute coronary syndrome in patients with chest pain who present to the emergency department, the clinical use of the History, Electrocardiogram, Age, Risk Factors, and Troponin (HEART) scoring has recently been proposed. This study aimed to assess the inter-rater reliability of the HEART score calculated by a large number of Italian emergency physicians. METHODS: The study was conducted in three academic emergency departments using clinical scenarios obtained from medical records of patients with chest pain. Twenty physicians, who took the HEART score course, independently assigned a score to different clinical scenarios, which were randomly administered to the participants, and data were collected and recorded in a spreadsheet by an independent investigator who was blinded to the study's aim. RESULTS: After applying the exclusion criteria, 53 scenarios were finally included in the analysis. The general inter-rater reliability was good (kappa statistics [κ], 0.63; 95% confidence interval, 0.57 to 0.70), and a good inter-rater agreement for the high- and low-risk classes (HEART score, 7 to 10 and 0 to 3, respectively; κ, 0.60 to 0.73) was observed, whereas a moderate agreement was found for the intermediate-risk class (HEART score, 4 to 6; κ, 0.51). Among the different items of the HEART score, history and electrocardiogram had the worse agreement (κ, 0.37 and 0.42, respectively). CONCLUSION: The HEART score had good inter-rater reliability, particularly among the high- and low-risk classes. The modest agreement for history suggests that major improvements are needed for objectively assessing this component.

Role of Internal Jugular Vein Ultrasound Measurements in the Assessment of Central Venous Pressure in Spontaneously Breathing Patients: A Systematic Review.

BACKGROUND: Few studies have tested the role of the internal jugular vein (IJV) ultrasonographic (US) diameters in the assessment of central venous pressure (CVP) in spontaneously breathing patients. No review or meta-analysis is currently available on the role of IJV assessment in this setting. The aim of this systematic review is to check the reliability and accuracy of IJV US diameters in predicting CVP and to evaluate its correlation with CVP in spontaneously breathing patients. METHODS: This systematic review was based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We included studies on the accuracy and reliability of the IJV ultrasound measures and studies exploring its correlation with CVP in adult spontaneously breathing patients. The studies' report quality was assessed by Standards for Reporting of Diagnostic Accuracy (STARD) and Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 scales. RESULTS: A total of five studies was eligible for final analysis. The studies on IJV ultrasound measures showed a good quality in reporting. The anterior-posterior diameter maximum of IJV (AP-IJV Dmax) showed the best correlation with the CVP with a good inter-rater reliability and validity in predicting CVP. All measures showed good inter-rater reliability and validity in predicting CVP, but only the AP-IJV Dmax showed good correlation with CVP. CONCLUSIONS: The AP-IJV Dmax could be a potential surrogate of CVP because of its good reliability and validity in predicting CVP value and its fair-moderate correlation with CVP. Anyway, further research should confi rm these conclusions.

A descriptive study of registered nurses' application of the triage scale RETTS©; a Swedish reliability study.

BACKGROUND: From a patient safety perspective, it is of great importance that decision support systems such as triage scales are evidence based. In the most recent national survey, the majority of Swedish Emergency Departments (EDs) apply the Swedish triage scale known as the Medical Emergency Triage Treatment Scale (METTS), subsequently renamed the Rapid Emergency Triage Treatment Scale (RETTS©). Despite national widespread implementation, there has been limited research on METTS/RETTS©. AIM: To determine the reliability of application by registered nurses of the RETTS© triage scale in two Swedish emergency departments. METHODS: In this prospective, cross-sectional study at two EDs, 46 written patient scenarios were triaged by 28 registered nurses (RNs). Data were analysed with descriptive statistics and Fleiss kappa (κ). RESULTS: The RNs allocated 1281 final triage levels. There was concordance in seven (15%) of the scenarios, and dispersion over two or more triage levels in 39 (85%). Dispersion across the stable/unstable patient boundary was found in 21 (46%) scenarios. Fleiss κ was 0.562, i.e. moderate agreement. CONCLUSION: The inability of the triage scale to distinguish between stable/unstable patients can lead to serious consequences from a patient safety perspective. No general pattern regarding concordance or dispersion was found.

A systematic review on the validity and reliability of an emergency department triage scale, the Manchester Triage System.

OBJECTIVE: To conduct a systematic review to check the level of validity and reliability of the Manchester Triage System and the quality of reporting of literature on this topic. DESIGN: This is a systematic review based on the PRISMA guideline on reporting systematic reviews. DATA SOURCES: The systematic search of the international literature published from 1997 through 30 November 2012 in the PubMed, Embase, Cochrane Library, Cinahl, Web of Knowledge, and Scopus databases. REVIEW METHODS: This review included quantitative and qualitative research investigating the reliability and validity of the Manchester Triage System for the broad population of adults and children visiting the emergency department. After a systematic selection process, included studies were assessed on their quality by three researchers using the STARD guidelines. RESULTS: Twelve studies were included in the review. The studies investigated the inter- and intra-rater reliability using the "kappa" statistic; the validity was tested with many measures: validity in predicting mortality, hospital admission, under- and overtriage, used resources, and length of stay in the emergency department, as well as a reference standard rating. CONCLUSIONS: In this review, the Manchester Triage System shows a wide inter-rater agreement range with a prevalence of good and very good agreement. Its safety was low because of the high rate of undertriage and the low sensitivity in predicting higher urgency levels. The high rate of overtriage could cause unnecessarily high use of resources in the emergency department. The quality of the reporting in studies of the reliability and validity of the Manchester Triage System is good.

Effect of a triage course on quality of rating triage codes in a group of university nursing students:a before-after observational study.

BACKGROUND: Most current triage tools have been tested among hospital nurses groups but there are not similar studies in university setting. In this study we analyzed if a course on a new four-level triage model, triage emergency method (TEM), could improve the quality of rating in a group of nursing students. METHODS: This observational study was conducted with paper scenarios at the University of Parma, Italy. Fifty students were assigned a triage level to 105 paper scenarios before and after a course on triage and TEM. We used weighted kappa statistics to measure the inter-rater reliability of TEM and assessed its validity by comparing the students' predictions with the triage code rating of a reference standard (a panel of five experts in the new triage method). RESULTS: Inter-rater reliability was K=0.42 (95%CI: 0.37-0.46) before the course on TEM, and K=0.61 (95%CI: 0.56-0.67) after. The accuracy of students' triage rating for the reference standard triage code was good: 81% (95%CI: 71-90). After the TEM course, the proportion of cases assigned to each acuity triage level was similar for the student group and the panel of experts. CONCLUSION: Among the group of nursing students, a brief course on triage and on a new in-hospital triage method seems to improve the quality of rating codes. The new triage method shows good inter-rater reliability for rating triage acuity and good accuracy in predicting the triage code rating of the reference standard.

Effect of a triage course on quality of rating triage codes in a group of university nursing students: a before-after observational study / 世界急诊医学杂志（英文）

BACKGROUND: Most current triage tools have been tested among hospital nurses groups but there are not similar studies in university setting. In this study we analyzed if a course on a new four-level triage model, triage emergency method (TEM), could improve the quality of rating in a group of nursing students.METHODS: This observational study was conducted with paper scenarios at the University of Parma, Italy. Fifty students were assigned a triage level to 105 paper scenarios before and after a course on triage and TEM. We used weighted kappa statistics to measure the inter-rater reliability of TEM and assessed its validity by comparing the students' predictions with the triage code rating of a reference standard (a panel of fi ve experts in the new triage method).RESULTS: Inter-rater reliability was K=0.42 (95%CI: 0.37-0.46) before the course on TEM, and K=0.61 (95%CI: 0.56-0.67) after. The accuracy of students' triage rating for the reference standard triage code was good: 81% (95%CI: 71-90). After the TEM course, the proportion of cases assigned to each acuity triage level was similar for the student group and the panel of experts.CONCLUSION: Among the group of nursing students, a brief course on triage and on a new in-hospital triage method seems to improve the quality of rating codes. The new triage method shows good inter-rater reliability for rating triage acuity and good accuracy in predicting the triage code rating of the reference standard.

Reliability and validity of an Italian four-level emergency triage system.

OBJECTIVES: To measure the reliability and predictive validity of a four-level triage system (I-4L). METHODS: This observational study was conducted in an urban hospital. Five nurses were randomly selected to assign a triage level to 246 paper scenarios, using the I-4L model. The I-4L model is a four-level triage system: urgency category (UC) 1 requires immediate response; UCs 2, 3 and 4 require assessment within 20, 60 and 120 min, respectively. Weighted kappa statistics were used to measure the inter-rater and intrarater reliability of the triage tool and the validity of the model was assessed based on the accuracy in predicting admission and in predicting a reference standard's triage code. RESULTS: The I-4L model's inter-rater reliability was kappa=0.73 (95% CI 0.67 to 0.79), and the intrarater reliability was kappa=0.82 (95% CI 0.67 to 0.96). Its accuracy of triage rating for admission and for prediction of a reference standard's triage code was good: 79% (95% CI 73% to 86%) and 93% (95% CI 89% to 96%), respectively. The percentages of patients admitted per triage level using the I-4L model was: 100% UC 1; 42% UC 2; 6% UC 3; and 2% UC 4. CONCLUSIONS: The I-4L triage model shows a good inter-rater and intrarater reliability for rating triage acuity and for accuracy in patient admission and prediction of a reference standard's triage code.

Reliability and validity of two four-level emergency triage systems.

OBJECTIVE: To measure and compare the reliability and predictive validity of a four-level triage system (I-4L) and the new four-level model triage emergency method (TEM). METHODS: This observational study was conducted in an urban hospital. Ten nurses were randomly selected to assign a triage level to 189 paper scenarios, using either the I-4L model (5 nurses) or the TEM model (5 nurses). We used weighted kappa statistics to measure the interrater and intrarater reliability of each triage tool and assessed the validity of each models based on the accuracy in predicting admission. RESULTS: Interrater reliability was kappa=0.73 [95% CI (confidence interval): 0.59-0.87] and kappa=0.79 (95% CI: 0.65-0.93) with I-4L and TEM, respectively. Intrarater reliability was kappa=0.82 (95% CI: 0.67-0.96) and kappa=0.78 (95% CI: 0.62-0.93), respectively. The accuracy of triage rating for admission prediction was similarly good with I-4L and TEM, namely, 79% (95% CI: 74-85) and 77% (95% CI: 74-85). The proportion of patients admitted per triage level was similar with the two models. CONCLUSION: The interrater and intrarater reliability for rating triage acuity and for accuracy in patient admission prediction was good with both models. Performance with the new model was similar to that of I-4L despite the nurses' short experience. The new TEM model has the advantage of predicting utilization of emergency department resources.

Cardiac troponin I as prognostic marker in heart failure patients discharged from emergency department.

Despite evidence that cardiac troponin I (cTnI) identifies patients with advanced heart failure (HF) at risk of death, data on heterogeneous HF populations are scarce. Our purpose was to verify and analyze the prognostic role of cTnI in acute HF patients admitted to the emergency department. This was an observational longitudinal prospective study carried out in an urban hospital. We studied 99 patients discharged from the department between March and December 2002 with a HF diagnosis and samples of cTnI. Patients with acute coronary syndromes, myocarditis or renal failure were excluded. The main outcome was death from any cause. The detection level of the cTnI assay was 0.05 ng/ml. cTnI was detected in 45.5% of HF patients. These patients had a higher NYHA class (P<0.001) at initial presentation and longer hospitalization (P=0.004) than cTnI-negative patients. Nineteen deaths occurred during the study: 17 for HF and 2 for acute coronary syndrome. Finally, detectable cTnI was associated with increased mortality risk (RR 4.7; 95% CI 1.3-17.1; P=0.021) also after adjustment for other adverse prognosis factors (age, NYHA class and presence of relapses). Our HF cTnI-positive patients had a worse clinical presentation and longer hospitalization. cTnI is a significant independent predictor of death and of longer hospitalization. It could be used for the early identification of HF patients at an increased risk of death in the long term, and of longer hospitalization. Thus, cTnI can aid decision-making and clinical management in the emergency department.

Thrombolytic therapy during prolonged in-hospital cardiac arrest.

We report a case of cardiac arrest secondary to acute myocardial infarction that was successfully resolved after thrombolytic therapy. This case suggests that thrombolysis can be used safely also during prolonged cardiopulmonary resuscitation for in-hospital cardiac arrest.

Left ventricular myocardial impairment in subclinical hypothyroidism assessed by a new ultrasound tool: pulsed tissue Doppler.

Pulsed tissue Doppler (TD) is a new ultrasound tool that allows quantification of myocardial regional wall motion. To investigate the cardiac effects of subclinical hypothyroidism (SH), the present study assessed left ventricular (LV) myocardial regional function in SH by pulsed TD. Twenty women with SH and 20 healthy women underwent standard Doppler echocardiograms and pulsed TD, placing a sample volume at the level of posterior septum and LV mitral annulus. Myocardial systolic and diastolic velocities and time intervals were determined for both levels. Doppler-echocardiographic and TD measurements were adjusted for body surface area and heart rate. Standard Doppler showed an increases in LV preejection period, preejection period/LV ejection time ratio, and isovolumic relaxation time (IVRT) in SH. By TD analysis, myocardial precontraction time (PCT(m)), PCT(m)/myocardial contraction time ratio, and myocardial relaxation time (RT(m)) were prolonged at the level of both posterior septum and mitral annulus in SH. In the whole population, IVRT, PCT(m), and RT(m) were negatively related to FT(4), whereas IVRT, PCT(m)/myocardial contraction time ratio, and RT(m) were positively correlated to TSH. In conclusion, this study underscores the usefulness of TD to detect cardiac functional abnormalities due to stable SH, mainly by changes in myocardial time intervals in several LV segments.